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i[} <br /> l <br /> 1. SEWAGE: <br /> Distance to Public Sewers: Connection necessary: Yes No <br /> Does existing septt'' system comply with San Joaquin County Development Title #549 ? <br /> Yes No / Unknown If no, explain: o , <br /> Describe septic installation to be installed: <br /> 2. WATER SUPPLY: <br /> Is water supplied by private well: Yes No Is weller:ro Y <br /> State deficiency: p p es NO <br /> Is well system a Public Water system? Yes No Is the permit current? Yes No <br /> Does existing or proposed use make this well Public Water: Yes No <br /> sampling current: yes No Is water/well <br /> Additional information or comments: <br /> 3. GARBAGE & REFUSE: <br /> Licensed scavenger pick-up: Yes No <br /> disposal method: Service Area No.:�� Other proposed <br /> Potential problem(s): <br /> 4• FLY MOS UITO OR VECTOR POTENTIAL: <br /> State possible vector potential and necessary control: <br /> 5. TOILET/BATH FACILITIES: <br /> Number and locations existing: <br /> facilities needed: Additional <br /> 6• PREVIOUS OPERATION HISTORY: <br /> 7• GENERAL SANITATION: <br /> State any problems not previously noted: <br /> 8• POPULATION DENSITY: <br /> Approximate number of people per square mile: <br />